Jeff Clawson, M.D.

Jeff Clawson, M.D.

Ask Doc

By Jeff Clawson, M.D.


I am trying to gather some information for our Executive staff regarding full implementation vs. partial use of EMD. Do you have any information regarding legal issues that stem from only using the pre arrival cards without starting with the case entry card? What, if any, are the state or federal laws that govern the use of EMD protocols as it would pertain to this subject? Thank you very much for any input you might have.

Thanks, Randy


Thanks for asking the Academy about this important issue. Stand-alone pre-arrival instructions are a clear violation and omission of the current standard of care and practice in the comm. center. Several documents at the federal level address this issue, including ASTM F-1258, National Institutes of Health (NIH) EMD Position Paper, as well as things in various state rules and regulations regarding EMD. Here are a few of them:

According to the NIH: “This is accomplished through the trained EMD’s careful use of a protocol that contains the following elements:

1. Systemized caller-interrogation questions that are chief-complaint specific

2. Systematized pre-arrival instructions

3. Protocols that determine vehicle response mode and configuration based on the EMD’s evaluation of injury or illness severity

4. Referenced information for dispatcher use”

They go on to state: “Systematized interrogation is an essential component of a comprehensive medical dispatch protocol…”

And in discussing the important purposes for dispatcher interrogation they emphasize: “Enable the EMD to determine the presence of conditions or situations requiring pre-arrival instructions.”

In addition, the American Society for Testing and Materials (ASTM) states in its document F-1258 sponsored and approved by the United States Department of Transportation (USDOT):

“Section 4.1.2: There must be continuity in the delivery of EMD care. To safely and effectively provide correct medical care, the EMD that is medically directing, evaluating and coding, must maintain direct access to the calling party and must use a medically approved emergency medical dispatch priority reference system. The person giving the medical instruction to the caller must be the same person that asks the systematic interrogation questions.”

In medicine, treatments are never provided unless we know first what we are treating. Case Entry is the primary survey for the calltaker, while Key Questions are the secondary survey of the case (whether patient or situation), and, depending on the particular issue at hand, are always done, unless the protocol clearly omits them for known pre-defined and approved reasons (the logic system).

In addition, provision of telephone-provided instructions that are simply based on a calltaker being trained in a procedure like CPR, the Heimlich maneuver, or childbirth, but not using a scripted protocol, has been vilified by the NIH as “telephone aid” and this “is usually considered an inappropriate and unreliable form of dispatcher-provided medical care.” In other words, training specific to the hands-on, visual environment of field medicine is not sufficient in the non-visual realm of dispatch where dispatch-specific training and scripted, protocol-based interrogation and instruction is required.

Failure to make these determinations has resulted in incorrect treatments resulting in death of the patient, injuring the patient, getting callers and bystanders injured or killed, as well as being an incomplete and completely incorrect method of dispatch evaluation and help.

When you consider that the correct use of a protocol is the equivalent of a pilot’s or astronaut’s pre-flight checklist, any omission can and often will have predictable and often catastrophic consequences. Thirty-five years into the correct provision of EMD, I don’t think such an approach should receive any further consideration, given the standards and norms of the current day.

Please let me know if any further information or clarifications would be helpful.

Best regards … Doc


This is very good information and will hopefully assist executive staff with future decisions regarding pre-arrival instructions. I think it is a great topic for discussion, and this might help other departments answer the question before any problems arise. I would like to thank you all for your assistance.

Thanks, Randy